Summary The single-engine Cessna210N aircraft, N104WF, serial numberP21000033, was en route from Narsarsuaq, Greenland, to Goose Bay, Newfoundland and Labrador, a leg of a ferry flight from Prestwick, Scotland, to the United States. The pilot was conducting a straight-in precision radar approach to Runway26 at Goose Bay in instrument meteorological conditions. Six nautical miles from the airport, the pilot radioed that the attitude indicator had failed. Shortly after the transmission, control of the aircraft was lost, and the aircraft struck the ice-covered surface of Hamilton Inlet, Newfoundland and Labrador. Both the pilot and her daughter were fatally injured, and the aircraft was destroyed. The accident occurred in darkness at 1809, Atlantic standard time. Ce rapport est galement disponible en franais. Other Factual Information The pilot had over 5000reported flying hours, held a commercial pilot licence, and was rated for instrument flight rules (IFR) flights. She was experienced in ferry pilot operations with 110trans-Atlantic flights. The aircraft logbook was recovered with the wreckage, and it showed that on 16November2000, the aircraft underwent maintenance at the Jersey Airport, Jersey, Channel Islands. Among the maintenance tasks completed were: replacement of the engine (Continental Teledyne TSIO-520P-5) with a zero-time engine; replacement of the vacuum pump; replacement of the emergency locator transmitter (ELT) battery (new expiry date June2002); and, certification of the aircraft as being airworthy. The aircraft was moved to Exeter, England, on 02March2001, where it was stored. Prior to being purchased by the new owner in January2003, the aircraft underwent another annual inspection on 18December2002, and was again certified as being airworthy. Maintenance records for work conducted on the aircraft from the time of purchase to the time of departure from Prestwick, Scotland, were not among the items found in the wreckage and could not be located. The maintenance history and outstanding defects for the aircraft in this time period were reconstructed from other sources. On 22January2003, the owner of the ferry company contracted to deliver the aircraft, picked up the aircraft in Exeter and flew it to Prestwick. During the flight, a list of maintenance deficiencies was compiled. The list included, inter alia: stuck cabin heat controls; poor pressurization; mis-adjustment of the propeller governor; engine running hot at cruise; excessive nosewheel shimmy; poor nosewheel steering; lack of an automatic direction-finding (ADF) receiver; a wandering horizontal situation indicator. After arriving in Prestwick, the major mechanical airworthiness items were rectified to the point where the aircraft could be flown under visual flight rules (VFR) by a local flying club to break-in the engine prior to the ferry flight. Meanwhile, efforts were made to further improve the general mechanical condition of the aircraft. During these flights the turn coordinator was found to be unreliable1 and the windows of the aircraft would occasionally mist up due to poor heating. The aircraft was not equipped with a standby attitude indicator. On 06 February 2003 the accident pilot flew the aircraft back to Exeter for more maintenance work, returning the aircraft to Prestwick on the evening of 07February2003. (This was the last time the accident pilot flew the aircraft prior to her departure on 12February2003.) The local flying club then flew two flights with the aircraft on 08February2003, and four flights on 09February2003. On 11February2003 the vacuum system filters as well as the engine oil and oil filter were reportedly changed. Two final flights were then flown by the flying club, with the last flight on the aircraft occurring on the evening of 11February2003. None of the flying club pilots noted any anomalies with the attitude indicator during any of the pre-departure flights; however the turn coordinator was observed to be unserviceable on the final flights before departure. The aircraft departed Prestwick for Reykjavc, Iceland, on an IFR flight plan on 12February2003. When the aircraft arrived in Reykjavc, the pilot commented that the aircraft's turn coordinator was unserviceable and the aircraft's heater was not working well. She did not, however, have these items serviced. The flight was delayed a day in Reykjavc due to a winter storm and departed for Narsarsuaq, Greenland, at 0730 Atlantic standard time2 on 14February2003. On arrival in Narsarsuaq at 1140, the pilot and her daughter were chilled due to the lack of heat, and the pilot commented that there was a complete lack of heat and pressurization. The two then went to a nearby hotel restaurant for lunch. The pilot received a weather briefing package prior to departing for Goose Bay. The weather forecast for Goose Bay for the time of arrival was as follows: wind from 360true at 10knots, visibility 5statute miles (sm) in light snow, a scattered layer of clouds at 2000feet, and a broken ceiling at 3000feet. The forecast also contained a TEMPO3 condition for the period advising of visibilities reduced to 2sm, and a broken ceiling at 2000feet. The weather forecast for the arrival time at the planned alternate airport, Churchill Falls, was sm in light snow and blowing snow, with a vertical visibility of 500feet. There was also a TEMPO condition, spanning the entire forecast period, which indicated a visibility of 2sm in light snow and an overcast ceiling of 1000feet. The actual weather at Churchill Falls was below alternate limits throughout the day. There are three published IFR approaches at Churchill Falls, but the aircraft was not equipped to fly any of them. The pilot filed an IFR flight plan for Goose Bay, with Churchill Falls as the alternate aerodrome. At 1428, almost three hours after its arrival, N104WF departed Narsarsuaq under IFR for Goose Bay on a direct routing over the ocean at 14000feet. Temperatures at altitude were below -30C. To compensate for the lack of heat in the aircraft, both occupants wore multiple layers of clothing under their cold-water survival immersion suits. At 1800, while 23nautical miles (nm) from the Goose Bay airport, the aircraft had descended to 2000feet and was cleared for a straight-in precision approach radar (PAR) to Runway26. Air traffic control radar data showed that the aircraft proceeded inbound at 2000to 2100feet, with occasional small corrections to maintain the on-course track (SeeAppendixA - Final Flight Path). At 1808, just inside 6nm from Goose Bay, the pilot radioed that the attitude indicator had failed. The PAR controller immediately reverted to NoCompass approach procedures, advising the pilot to disregard the compass. Shortly after the pilot's transmission, the aircraft veered left, descended rapidly to 1400feet, then levelled on a northerly heading. The PAR controller then discontinued the approach and attempted to aid the pilot by advising of necessary corrections to the flight path. The aircraft stayed on a northerly heading for approximately 20seconds climbing gradually to 1600feet; it then entered a spiral dive to the left. The PAR controller initiated a search immediately upon losing radar and radio contact with the aircraft. The aircraft wreckage was found by ground searchers at about 0100 hours on 15February2003. The search had been hampered by darkness, reduced visibility in blowing snow, and the lack of an ELT signal. The aircraft struck the ice-covered surface of Hamilton Inlet, 5nm east of the airport, at 1809 (one hour after local sunset), in a left-wing-down, nose-low altitude, at a high speed. The speed and attitude of the aircraft were consistent with the aircraft being in a spiral dive at impact. The impact was not survivable. The aircraft was substantially damaged when it struck the ice, with a wreckage trail that was 160feet long, heading 118magnetic. The wing structure was torn from the fuselage, with most damage to the left wing. The engine compartment, instrument panel and cabin area was destroyed. A strong smell of fuel was noted at the accident site after the occurrence. Numerous aircraft components were recovered along the wreckage trail; however, some items were not found. The ice at the initial impact point was fractured, and it is believed that portions of the wreckage penetrated the ice and settled to the bottom of the inlet. Among the missing items was the turn coordinator. The aircraft was inspected on-site and in a hangar environment. No pre-impact discrepancies were found with the flight controls which would have led to a loss of control. The gear was fully extended, and the flaps were fully retracted. The elevator trim tab was in the neutral position according to the trim tab actuator. The attitude indicator was found, damaged but intact. Other components of the vacuum system were also recovered and were forwarded to the TSB Engineering Branch for examination. The examination showed that the attitude indicator gyroscope was not spinning with appreciable energy at the time of impact, and that the vacuum driven directional gyroscope exhibited indications of normal operation. This suggests that suction was being created by the vacuum system, but the attitude indicator, or system plumbing directly associated with only the attitude indicator, had malfunctioned. The ELT was torn from its mount and was found midway along the wreckage path. The case was cracked, and the antenna had been torn free. The ELT activation switch, which has three positions, Armed for automatic activation, On, and Off was found in the Off position. The ELT battery was time expired, with a replacement date of June 2002. The ELT battery was bench checked after the accident, and produced a voltage of 6.03volts where 9.00volts is the full charge voltage. The reduced voltage produced by the time expired battery would have resulted in a weakened signal, lessening the chance of detection. The ELT unit was activated during the check and was functional. Had the ELT activation switch been in the Armed position, it is possible that a weak signal would have been produced. The Goose Bay weather at 1800 (nine minutes prior to the accident) was as follows: wind 250true at 20gusting to 26knots, visibility sm in light snow and blowing snow, and overcast ceiling at 1700feet. Another pilot flew the same PAR approach to Goose Bay about 30minutes after the accident. He reported that he entered cloud at 6000feet on descent, and was in instrument meteorological conditions (IMC) at five miles. He remained in IMC until he acquired the runway lighting between 1500and 1000feet on final. There was no icing in cloud. The weather at Churchill Falls at 1942, near the expected arrival time had a diversion been necessary, was as follows: wind 310true at 25gusting to 32knots, visibility 1/8sm in light snow, vertical visibility zero, remarks sky obscured. Fuel consumption calculations were made using the flight times and fuel upload information from the previous legs. These calculations showed that there was an estimated 1.6hours of usable fuel remaining at the time of impact. The approximate flight time to the alternate airport was 1.5hours. The Canadian Aviation Regulations (CARs) require that where an alternate aerodrome is specified in the flight plan, the aircraft must carry sufficient fuel to fly to, and execute, an approach and a missed approach at the destination aerodrome, to fly to and land at the alternate aerodrome, then to fly for a period of 45 minutes. The aircraft did not carry sufficient fuel to meet the CARs fuel requirements. The Flight Manual for the Cessna 210N contains instructions for emergency operations in clouds. The instructions assume that only the electrically-powered turn coordinator or the turn and bank indicator is operative, and that the pilot is not completely proficient in instrument flying. Part of the corrective action for recovery from a spiral dive is to stop the turn by referring to the turn coordinator. The turn coordinator had been reported to be unserviceable prior to the aircraft departing Prestwick.